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Particle Repositioning for BPPV

Philip Littlefield, MDOtology & Neurotology

Tripler Army Medical CenterHonolulu, HI

The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government.

Objectives

• Anatomy & Physiology

• Findings & Treatment– Posterior Canal

– Horizontal Canal

– Anterior Canal

• Mimickers

• Coding & Reimbursement

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Vestibule

Excitation

Lateral Canal Crista Ampullaris

Ewald’s First Law: Eye movements are in the plane of the semicircular canal, and in the direction of the endolymph flow.

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BPPV Exam

Start seated– Neck mobility

– Cervical-induced nystagmus

– Rotational vertebral artery syndrome

BPPV Exam

• Right Dix-Hallpike– Roll test (if horizontal nystagmus)

– Reverse Dix-Hallpike (it depends)

• Left Dix-Hallpike

• Supine head hanging (bring back up first)

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LC

AC

PC

Right EarLateral ViewSitting

g

LC

ACPC

Right EarLateral ViewDix-Hallpike20° Head Hang

g

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BPPV Characteristics

• Direction

• Latency

• Duration

• Fatigability

• Reversibility

Directions of Nystagmus

• Posterior – Upbeat with geotropic torsion

• Anterior – Downbeat with torsion to bad ear

• Lateral– Geotropic horizontal (common)

– Apogeotropic horizontal (uncommon)

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Right EarPosterior Canal BPPVGeotropic & Upbeat

VNG Goggles

• Not necessary - torsional nystagmus not visually suppressed

• But they sure help– Non-torsional nystagmus

– Can see in awkward positions

– Recordings give you time to think

Dmitry Kostyukov/AFP/Getty Images

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Semont

http://www.neurology.org/content/70/22/2067/F3.large.jpg (modified)

Right Posterior Canal

Brandt-Daroff

http://www.neurology.org/content/70/22/2067/F3.large.jpg (modified)

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Epley Maneuver

http://hearingaidscentral.com/BPPV_Epley_Maneuver.asp

Right Ear

Canalith Repositioning ManeuverPosition A (Sitting)

Right EarLateral ViewPosterior Canal BPPV

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CRM Position B(Dix-Hallpike)

Right EarLateral ViewPosterior Canal BPPV

Right EarLateral ViewPosterior Canal BPPV

CRM Position C(Head Rotated To Opposite Side)

Keep the head back as you rotate it.The nystagmus should not reverse direction.

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CRM Position D(On Side - Nose Down)

Right EarLateral ViewPosterior Canal BPPV

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Right EarLateral ViewPosterior Canal BPPV

CRM Position E(Back To Sitting)

Stabilize patient for at least a minute.

http://www.vesticon.com/The_Epley_Omniax/Epley_Omniax_Gallery

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Adjuncts

• Vestibular suppressants– Hide findings

– Useful for severe nausea

• Mastoid vibration – no help1-2 (except)– Multiple failures

– Cupulolithiasis

1Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000; 122(3):440-4.2Burton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane Library: Modifications of the Epley maneuver for posterior canal BPPV. Otolaryngol Head Neck Surg 2012; 147(3):407-11.

Post-Care

• Post-treatment restrictions do not help1-4

• Seat in waiting room for 20 min

• No driving for remainder of day

1Tusa RJ, Herdmann SJ. BPPV: Controlled trials, contraindications, post-manouvere instructions, complications, imbalance. Audiology Medicine 2005; 3(1):57-62.2Nuti D, Nati C, Passali D. Treatment of BPPV: No need for post maneuver restrictions. Otolaryngol Head Neck Surg 2000; 122(3):440-4.3Andreoli SM, Devaiah A. Posture restrictions in BPPV. Otolaryngol Head Neck Surg 2007; 137(2): 258.4Burton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane Library: Modifications of the Epley maneuver for posterior canal BPPV. Otolaryngol Head Neck Surg 2012; 147(3):407-11.

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Epley vs. Semont

• Epley – 80 to 85% effective after one session1

– Easier to do

– Better tolerated by elderly

• Semont – 90% effective after four sessions2

– Better for cupulolithiasis?1Epley JM. The canalith repositioning procedure: For the treatment of BPPV. Otolaryngol Head Neck Surg 1992; 107(3); 399-404.2Levrat E, van Mell G, Monnier P, Maire R. Efficacy of the Semont maneuver in BPPV. Arch Otolaryngol Head Neck Surg 2003; 129(6): 629-33.

Horizontal Canal

LC

AC

PC

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Geotropic

GeotropicRight Horizontal CanalDebris Near Vestibule

Left Ear DownInhibition

Supine Right Ear DownStimulation

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Apogeotropic

ApogeotropicRight Horizontal CanalDebris Near Ampulla

Left Ear DownStimulation

Supine Right Ear DownInhibition

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Lempert Roll

http://www.neurology.org/content/70/22/2067/F5.expansion

Right Horizontal Canal

Right Horizontal CanalLempert Roll

1

3

2

4

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Horizontal Canal In The Office

• Geotropic – roll away from the strongest nystagmus

• Apogeotropic – roll toward the strongest nystagmus, convert to geotropic

• Cannot tell which side – guess

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Horizontal Canal At Home*

• Log roll to one side daily for one week

• Switch sides if that does not work

• Sleep with bad ear up

• Modified Brandt-Daroff (head straight) - to loosen up possible cupulolithiasis

*Only necessary if office treatments fail.

Anterior CanalRight EarLateral ViewSitting

gAC

PC

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Right EarAnterior Canal BPPVGeotropic & DOWNBEAT

Left EarAnterior Canal BPPVAPOGEOTROPIC & Downbeat

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Anterior Canal Strategy

Deep Head Hang ManeuverHead Midline – the effected side does NOT matter

Mimickers

• Horizontal – Positional alcohol nystagmus

• Downbeat – Caudal midline cerebellar lesions

• Upbeat – Dorsal central medullary lesions

• Torsional – Syringomyelia and syringobulbia

• Persistent – Somewhere central

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Billing - 95992

• Medicare – 45.12

• Aetna – 64.29

• Cigna – 87.75

• Humana APP – 50.13

• First Health – 73.50

• BCBSA – 57.00

• DMG – E&M only

Thank You